hello my name is dr. Paul may Oh I work at North Shore University Hospital lij in the northwest system in New York City area I'm also a clinical professor of medicine at the Hofstra northwell School of Medicine yoni my name is Yonatan Greenstein I'm an assistant professor of medicine at the Rutgers New Jersey Medical School in Newark New Jersey where I practice pulmonary critical care and sleep medicine yoni why are we here so we're here in Glenview Illinois at the chess global headquarters because we are very passionate about critical care ultra sonography and we want to help those clinicians who are interested in taking the next step from basic critical care ultra sonography to advanced critical care echocardiography the National Board of echocardiography has set up a national level certification for advanced CRO care echocardiography also known as ACE as in the ace of hearts there will be a examination of full high stakes board exam that will be given in January 2019 in addition there'll be a requirement to demonstrate full capability in advance crew here echo image set and that's why you're here today now we find that when clinicians are first learning the full ACE image set it takes about 20 to 30 minutes for a single exam but after several have been done the full exam takes between 8 and 11 minutes sometimes longer sometimes shorter yes and one of the main questions we receive when we're giving conferences on the matter of courses is what is the full examination and that's why we're here to demonstrate the full image set that would be required at a minimum for each examination that is carried out in order to demonstrate capability correct absolutely yoni you've now completed your candidate for and you've completed last count I believe between 99 and a hundred full examinations over the course of your fellowship yeah you still keep holding on to that last one but I you got to give me credit that have gotten my hundred examinations and you've become an expert level scanner in my opinion I'm your supervisor I review your studies so why don't we go over to our model and go through the full exam the purpose being that the candidate then has a benchmark these are the images that I must collect as I'm setting up my portfolio being a serious candidate for career care echocardiography okay certification correct let's do it a word of caution that you want to have full mastery of goal-directed echocardiography before you undertake any training in ace you'd agree with that absolutely yoni you're gonna direct me through the entire examination in one in just one go correct that's correct we've learned that you need a lot of direction so I'll be here right behind you to help thank you for this may I give a few introductory words here char please yeah for example the audience will notice that because I'm doing a full exam for training purposes I am physically comfortable the machine as well orientated I've been I'm sitting down because the uncomfortable scanner will always fail in good image quality I'm also on the right side primarily because of camera angle and as a caution anybody who masters ace must be able to be completely ambidextrous in their scanning skill we happen to be on the right side because it's practical issue there are some other issues that sometimes comes up that sometime come up for example the probe cord some people put it around their shoulder it's nice-looking position here on the other hand in the ICU were worried that maybe that's a full might so others prefer to lay it on the bed and not on their body itself a few other things there's some controversy about how much gel to apply some would place a little bit here and on the probe itself problem with that approach is that you'll be doing the application multiple times the true ace expert says I'm gonna put enough gel on so I can do the entire examination without having to constantly reapply it yoni please give me some direction here so let's first show the Lerner's probe manipulation and what the different movements are called and these are standard terms that have been developed by the cardiology community forty years ago and we use them in our work correct threat our experience has been that the terms are often misused so we'll spend a moment here so one of the first manipulations is to angle the probe this is angling correct that's correct the next manipulation will be tilting the probe where you're tilting the tomographic plane along the axis of the topographic plane and rotation which is as it sounds turning the probe without angling moving or tilting it at all just rotating it correct correct and finally there are simple movements the physical movement of the probe is to find as moving and it's important now with the ace exam to think about all of those probe manipulations separately as you're making your adjustments okay what should i do first so we're gonna start first with the parasternal long axis view of our all set gained right here and I think the depth is properly adjusted and I've achieved a standard acceptable axis after we have achieved our initial view we'll first start with some color Doppler and we'll look for mitral regurgitation and you'll notice that dr. Mayo is working on appropriately sizing his Doppler sample box and you want it to include the entire atria and also go over the mitral valve a little bit and we don't see any evidence of mitral regurgitation here he's next gonna move the Doppler sample box to look for aortic insufficiency and again he is overlapping the aortic valve with the LV OT and we don't see significant aortic insufficiency after this he's gonna fire up the M mode capability and he's gonna do three different things first he's gonna look along the left ventricle where he's going to do an assessment of the LV size during diastole and during systole notice that I've moved the probe a bit and also I tilted it in order to achieve a better access for M mode you want the M mode line to be perpendicular to the ventricular walls as much as possible so I'm trying to fight for that that's a weakness of M mode it's very much angle dependent I'll activate it at this point an accurate measurement here can be quite difficult in our intubated mechanically ventilated patient sometimes it's simply not possible to get this perpendicular I'm required to make some measurements so I'm a little concerned that the m-mode line might be a little bit low in the ventricle you like it really at the papillary muscle level but I'll show you how the measurements are made we activate our measurement capability I do not see the right ventricular wall very well nor the right ventricular outflow tracts shall we start with the interventricular septum yes sir all right and we would want to make it during diastole you know you only have noticed that we we don't have a we don't seem to have a EKG on this patient what's going on here we're functioning right now in the reality of a lot of American intensive care units where our resources do not afford us some of the bells and whistles that we would like luckily for a lot of the advanced for the care fo examination we can deduce what part of the cardiac cycle we're in so here you are making the assumption that the largest ventricular cavity is during diastole and that's how you're basing your measurement and I think that's quite accurate there's the septal distance will then select select and now we have the ventricular cavity at n diastole and we'll hit select and then the inferior lateral wall rather difficult to pick out here because we have a contribution from the papillary muscle I'll put the pericardial interface here and I'm looking for the most continuous most angulated line and I'll move my I think this is a little bit high there how do I change them back and forth Joanie I don't think good option to change in there yeah alright so this would be a gross estimate so let's do the mo scan lines through the mitral valve and the aortic valve while we're here all right those are quite straightforward here snow here I activate I see normal movement of the mitral valve and we have a specially important measurement to make here which is called the EP SS for example separation right and that is related to some extent to assessment of ventricular function it's an indirect measurement if the EP SS is greater than 10 millimeters it supports the possibility of LV dysfunction here we have six millimeters which is normal range okay and then we'll make an estimate of left atrial size is that the next with M mode and we would like to come through the Artic valve here and we will turn on m mode and we see opening and closure of the aortic valve and we would measure the end systolic side of the left atrium caliper on and we go edge to edge by ASC definition and we select we drop that down so that's normal range we'll save that image there are a lot of other things you can do with M mode these are the basics M mode in many ways as a generational issue a lot of modern echo labs don't really use it any longer but has some interesting of applications for detailed analysis of valve function and wall motion so from here the next view that I like to - is the right ventricular inflow view which dr. Mayo is going to obtain by angling the probe medially okay so this is the first view that the goal-directed echocardiography is really not familiar with I've angled in to look at the right side I'm wondering if a lateral decubitus yeah let's ask Bryant if he could roll over a little bit this way please thank you yeah all right okay good now I'm sitting sitting now I'm seated comfortably on the bed I'll find that person along right away it's easier to get that I'll angle inwards here we have the RV in flow view yoni should I take the group for a tour yes okay here's the right atrium here is the IVC inflow here is the tricuspid valve and here is the right ventricle and of course the ACE expert always colors every valve to see if there's a regurgitation jet here I don't pick one up but if we saw one it is mandatory then to measure the velocity across yeah and I'm gonna ask you to make a larger sample volume box let's assume that there was rehearsing jet in order to better see it you want to the entire atria okay so I'll make that a little larger is that good enough for Newark New Jersey that is yeah a little bit more stringent criteria than out there on Long Island yeah I know can you can you play on continuous just show so we change it here and if we saw a TR jet we would place it down through the vena contracta that's at the site of origin of the jet and we would attempt to measure the trance of the tricuspid regurgitation velocity from which we could derive an estimate of pulmonary yeah pulmonary systolic pressure correct we don't see any here let's hit the doppler button just to show them what it would look and also Starling to which direction alright so we would target it with color we would then turn on CW find the jet which we don't have here and you would like me to activate and this is how the this is what the the tracing would look like and if we had a jet and we'll show those in a lot of the abnormal image sets that we're gonna send over to chest you would make the measurement very easily be a negative velocity negative velocity no the line not above what okay so what is the next standard view for the ACE examination so we now move back to the Paris tonal short access view hmm which our basic repair echo colleagues will be familiar with and the basic colleagues will be familiar with the mid ventricular also known as papillary muscle levels let's start there all right so we rotate 90 degrees and we'll start a papillary muscle level everyone is familiar because everyone who's interested in ace has full capability at goal-directed echo and then I would propose we do segmental wall motion abnormalities we do septal kinetics we then angle down to look at the apical segments and then we start angling up to the mitral valve level which we define the basal segments and you can do a full segmental wall analysis with ace capability simply by looking at those three levels correct and we'll typically put color Doppler at this point yeah if you wish we'd look for mr from a somewhat unusual level right here okay all right um we then go to the base of the heart and in the center of the screen we examine the anatomy of the aortic valve I do not have clear closure point but I think this is a tri leaflet valve morphologically it's normal within the context of imperfect image quality and then we would color this just as we did with the parasternal long axis view of the aortic valve to look for regurge which we do not see yoni what's the next valve we should look at let's look at the tricuspid valve and so I tipped over to the tricuspid valve and this will be over in this area I'm gonna try to scan through it and whenever I see a valve I will always put color on that valve to look for tricuspid regurge if we saw it which we don't I would then place the CW line right through the origin of that jet and I turn on Doppler I would freeze I would make a measurement the next yoni so that's what we look for the pulmonic valve which we see quite nicely on this view yeah so I'm tilting over to look a little towards the left and I can see the pulmonic valve which is right here okay so I will then activate the color ah look there's a little bit look at that yeah that's actually quite common in normals it's a normal variant so as soon as we see a color jet of any sort we want to measure the velocity across that valve I'm not sure we're gonna pick it up but let's give it a try we're off angle so this will be an under estimate of velocity but I'll see if I can get a little bit of a little bit of a signal here yeah in fact we do i'll change scale so I'm going to shift my my probe angle a little bit to try to get a better Doppler angle here we have it and Doppler I'm going to try to find the origin of the jet there we go activate I don't think we're picking up the PR jet and I would point out that as critical care intensive this we are interested in significant repair tation Jeff yeah this is person that's not something really worth spending our time trying to measure I'm now going to move the probe a little bit downwards and I'm going to vend angle up to try to find the pulmonary order the main pulmonary artery here it is right here and as soon as we see that we're going to make measurement of the acceleration time correct that's correct right and we use pw for that yes yeah I put the sample volume here in the main pulmonary artery i activate and i'll try to get a good view here i had one for a moment i'll try once more right here get a little closer the valve right here doppler on yoni what do you think the image quality is quite optimal this is where our transesophageal echo really wins the race for better in the juniors we'll still so show how to make the measurement so the interval between the onset of the velocity envelope and its peak is 155 milliseconds which indicates this patient does not have pulmonary arterial hypertension that correct okay we'll take maybe a sub cost of view if we can find it to make the same measurement okay so does that pretty much complete the base examination leads the parasternal views so we're now going to move to the apical for chamber view of the heart our patient's already in a good left lateral decubitus position if the patient was not in that position already now is a good time as it will dramatically improve your imaging quality for these more advanced measurements I think the depth axis and gain is acceptable here we made a near field gain we can turn down a touch okay okay I'll drop to a wonderful space more lateral to see if I can thin out the the apex but I don't know yeah I think this is probably probably the best I can do right around there a little worried I'm a little for shortening the apex but more lateral I lose image quality is this alright for our purposes I think yeah and the goal-directed echocardiography of course uses this primarily to size the RB at the LV but now in ace territory we make a lot of other different measurements correct that's correct let's first start by doing simpler cut simple color Doppler to look for reversion Jets box size I'll maybe make a little bit smaller yeah okay we do not see mitral regurgitation and now dr. Mayo is gonna move the box over to look for a tricuspid regurgitation the audience will notice that I'm scanning through the valve by angling my tomographic plane valves are three-dimensional structures of course it's important to do that over/under tricuspid side likewise I scan through the valve a bit there's no TR and there's no there's no mr nothing to measure there yep you agree yes okay so we can now move on to our assessment of diastolic function and we typically start by using pulse wave Doppler to measure mitral inflow we have to be very cautious here because dr. Greenstein is first author on a major review article on diastolic function evaluation by the intensivists I was in chest I think either this month or last month a good read but again he's an expert what should I do so let's take that PW and you're gonna place the sample volume box at the mitral valve leaflet tips within the left ventricle then you're gonna hit Doppler again we're looking at is the flow that's going towards the sample by us which is tort approach we're looking at the losses that are possible out in an ideal world we would have ECG means attached but we're functioning in a realistic somewhat somewhat on ideal world let's let's imagine that our single ECG lead has been stolen or lost by one of the medical residents in the hospital and so we're gonna make some assumptions that this patient has normal diastolic function and with dr. Mayo is doing is he is measuring the e wave which is early mitral filling during diastole and then he's measuring the a way of subsequently and in between he's gonna calculate the pressure halftime yeah and this is an archaic measurement except for very specialized applications the D cell time or the pressure for half time rather will jump forward to the a wave and that gives us an e to a weight a ratio correct correct all right and it's beyond the scope of this series to go into this in more detail other than how to acquire the measurements okay and for full evaluation of diastolic dysfunction and for estimates of left atrial pressure you're going to ask me to do what so we're now going to use pulse wave Doppler with tissue Doppler imaging TDI to measure the velocity of the mitral valve annulus and we can measure either or both the lateral annulus or the septal annulus the doctor man is just getting a workable image you'll notice he's moving his pulse wave Doppler sample box and he's turning tissue Doppler imaging on and now what he's looking at is the velocity that's moving away from the probes with a negative velocity and just like in flow there's an e which is now called E Prime and an a which is called a prime he's gonna measure those and this is where ECG is really crucial and helpful because right now it's a little bit difficult to tell which is which so we would go to main we then go to the TDI selection we're gonna do a lateral EEPROM correct all right now I'm identifying this area as the systolic movement of the annulus therefore this is the a prime and this is the e prime that's correct so 15 and we say that's how the guerrilla ultrasonographer figures things out right v kg would be a lot easier and my conclusion here is that this patient is normal velocity of T normal t di velocity lateral annulus you could do the septal if you wanted to be if you want to be complete I don't think it's necessary this is normal velocity and that virtually excludes diastolic dysfunction and the ratio of e to e prime would give you an estimate of left atrial pressure which in this case will be normal range that's correct okay good all right from the apical for chamber view we next go to the apical five chamber of view so that we can measure the velocity time integral over the left ventricular outflow tract as an estimate of cardiac output so doctor Mao is gonna use PW and turn off the tissue Doppler in the jig and he's going to adjust his sample run a sweep speed to optimally image about this velocity and the flow is going from the LV over the LV ot away from the probe and it's the velocity that is negative that's below the line and he's gonna manually trace the curve and this will be directly proportional to the stroke volume and if we if we knew the lv OT diameter it would be a simple arithmetic Oh Calculon for stroke volume correct that's correct and the LV OT diameter is easily calculated at the parasternal long axis view of our normal range is 18 to 22 centimeters that's correct Bryant is a normal subject this is no surprise to us correctly and we're happy with the positioning of your sample box because we see a heard about closure at the end of systole mm-hmm all right as long as we're here should we take a quick look at right-sided function in terms of measuring the tap see that's what you like to do what does that stand for tap see such tap C stands for tricuspid annular claim systolic excursion and it's a surrogate measure to help estimate how our V systolic function is and what dr. Mao has done is he's turned M mode imaging on and he has passed the on mode scan line through the lateral through the lateral annulus of the tricuspid valve and he's measuring the height difference between systole and diastole a normally functioning ventricle on the right side there'll be quite a bit of movement of the annulus as we see here it's 22 millimeters and that is a normal movement normal tap c22 no one's surprise correct correct yeah okay all right next so we now move to image the ventricle and the valves and other orthogonal views so we move from the apical for chamber to the apical to chamber view I rotate my probes 60 degrees to achieve a two chamber view and that was a counterclockwise rotation and for the ACE candidate who must know all sixteen segments there are actually seventeen segments but we'll say there are sixteen this is the anterior wall and this is the inferior wall and then to continue the rotation to another six degrees we have the three chamber view this is the anterior septum and this is the inferior lateral wall if necessary m-mode can be a facade if necessary color can be applied to these vowels in this case we would not regard it as necessary an alternative means of measuring the vo2 vvt-i is to measure it here and that has the same implication as measured upon the five chamber view correct now you would agree that for the intensivists or clinician who is delving down the ACE path it will be a required measurement to do so there should be color Doppler done at all of these angles for a complete image sir yeah we would we would advise that and you would measure vti here and let's see how does it compare yes so you always take the higher value because of the issues related to Doppler and angle of the insulation correct correct all right normal range great all right what's next we now move to the subcostal long access view of the heart all right oh okay there we go all right I'm trying to adjust my probe position and also to umber five tomographic angle in order to show both ventricles as horizontal as possible on the screen this is a familiar view to the goal-directed echocardiography you can of course if necessary color these vowels particularly the tricuspid valve sometimes it offers a good angle for insulation for measurement of Trance valvular velocity now we like this view besides for regurgitation because we can also look at the IVC which is something done in the basic exam right and before we go there let's do a short access view of a left ventricle there we have something that's rather equivalent to the parasternal short axis view and if you fail with parasternal short then this is the bailout view to get the same information obviously we then move the tomographic plane a little bit over towards the right hoping to find the pulmonary artery and I think we have a little bit of colonic gas up here that's blocking us a bit so we may be unsuccessful here's some sort of air artefact so I don't think we're gonna be able to see the pulmonary artery although I can just see it unraveling here let's see if we can make that Doppler measurement sometimes bad 2d image you still get Doppler information see we get here ah there we have it yeah look at that what do you think yeah yeah yeah we got lucky all right so we'll go to calc and we're gonna make a measurement of acceleration time which was 155 initially let's see what it is here okay this is the main pulmonary artery velocity time integral I place my initial cursor here and peak is right around so this is I think more accurate than the first one you agree pretty good except our upstroke yeah it's it's a it's acceptable although not perfect quality the patient does not have pulmonary arterial hypertension correct correct all right really the final view is to measure the hepatic vein inflow at the IVC I am NOT able to image the IVC as it comes into the right atrium simply because we have air artifact that is transverse colon so we'll be unsuccessful in finding the inflow of the a patek vein until such time that that gas moves through however we might get lucky by coming a little bit more lateral and let's see can we find something it can help us let's see there's the IVC there but I don't think yoni you'll be disappointed well show us some views that are not necessarily part of a full examination that you would show to a mentor but they're interesting how about showing us a map see and the s1 velocity of the lateral mitral annulus which have been somewhat validated is indices that reflect LV function sure with obvious limitations so you'll recall before that dr. Mayo did tap C by putting the M mode scan line out here map C is gonna be the mirror opposite where we put the unmowed scan line out to the lateral annulus of the mitral valve and then we hit M mode again and we let it sweep across the screen and then we can do our same measurement and peculiarities of this machine is that you think you're measuring the hypotenuse of a triangle and in fact the number gives you is the vertical distance this case is one point five nine centimeters which is normal range for maps which is always a little lower than the normal for town see the principle here is that the higher the greater the movement of the modular of the mitral annulus the more normal is the function of the heart that applies during diastole it also applies during systole so could you measure here the distance but why don't steal a measure the velocity yeah so map C was done with M mode and to measure the velocity we place a pulse wave Doppler sample box over the same area the lateral annulus of the mitral valve and then we turn tissue Doppler imaging on and I'm gonna adjust the scale this was good I sorta have better quality oh here we go again he's always giving me a hard time I think I think you need new glasses maybe yeah yeah all right let's for those feedback for those of you who know dr. mail well you'll know he's often wearing his wife's glasses because he can't tell the difference I like that that's okay okay so we've got the e Prime and a prime and then we have the upward movement there on the screen that's the s-1 and we're able to measure velocity these are simple measurements that evaluate LV function are they fully validated for use in food here not really but they're interesting to make and they will probably have some future application plus are there any other specialized measurements that I'm not quite necessary full ace examination love interest one trifle pulmonary venous inflow sure such probably my least favorite measurement to do and there's a reason for that that the literature is very specific that with transfer a saket code and I would say especially in the quickly ilds they're already hard to get a good quality image they'll try for a little deep room there may be absolutely over now all to et toi okay thank you see I would put it I think there's an inflow right here yeah they fix my angle you can see they're there right that's right I can't slow the sweep speed will change line yeah and here we have I think the quality image is actually acceptable without EKG it's going to be very very hard to interpret so we'll say I wish we had the EKG too late but there's an example that's actually obtainable transesophageal echocardiography gives a really really easy and good quality very great Ninasam quo but it's application now is more limited than it was 10 years ago it's not part of the standard assessment for diastolic function or LMP preferences and remember correctly that's correct it well you need I understand you have some expertise fenced off to you like a choreographer I did I've done 33 examinations okay quite a European standards you're nearly at the point of credible capability for the audience transesophageal image acquisition will not be a requirement emphasis not be a requirement for MBE certification process that will likely be an add-on in five years or so when more units actually improves so don't worry about that